“Interspecialty referral of oesophagogastric and pharyngolaryngeal cancers delays diagnosis and reduces patient survival: A matched case-control study” – A medico-legal perspective

The Article

A team of clinicians from Poole Hospital NHS Foundation Trust and the University of Southampton, including TMLEP Members Professor Nouraei, Ms Heathcote and Ms King, have studied the incidence and significance of pharyngolaryngeal and oesophagogastric cancer referrals initially presenting within other specialties such as gastroenterology and otolaryngology.

With a common presentation of these cancers being problematic swallowing symptoms, they are often assessed first by gastroenterologists or otolaryngologyists before oncologists. Rapid and confident exclusion (or treatment) of cancer is a staple of assessing the pathway for patients and so, when presenting outside of oncology, correct treatment plans are paramount. Referral-to-diagnosis timeframes for cancer when undertaken by multiple specialties can delay the eventual diagnosis up to 3 times longer and therefore diminishes the survival rate and increases the likelihood of missed cancers significantly. There needs to be an integrated approach for diagnosis between the various specialties.

The study concluded:

“Significant numbers of patients with pharyngolaryngeal and oesophagogastric cancers first present to the specialty whose diagnostic focus and clinical skill set have not been historically optimal for the detection of that cancer. This may have contributed to over 30% of these cancers being missed. An interspecialty referral is associated with a significant increase in the time to cancer diagnosis and is an independent risk factor for reduced patient survival. In addition to raising awareness in the gastroenterology and ENT communities that this problem exists, a more patient-centred approach involving primary and secondary care specialists is needed to optimise referral pathways, and once a referral has been made, it is important that evaluation takes place in the context of an integrated pathway to ensure patients have the greatest chance of having their cancer detected or confidently excluded at the earliest possible opportunity.”

Medico-Legal Perspective

As part of TMLEP’s ongoing directive to raise awareness of the risks of litigation surrounding patient care, it is important that clinicians are mindful of the following to help reduce incident recurrence and ultimately enhance patient safety:

  • There is a growing pool of evidence that pharyngolaryngeal and oesophagogastric cancers can be missed when patients are seen by specialties whose clinical focus is not primarily cancer related, especially where there is a presenting symptom of problematic swallowing.

  • When patients present with problematic swallowing and the examining clinician is not a cancer specialist, it may be worth considering an interdisciplinary referral to ensure cancers are not missed.

  • Healthcare providers may need to review their internal and external referral programmes to ensure that where a patient presents to one specialty, they can expeditiously be referred onward to prevent any delays in treatment.

To Summarise

To summarise, it is clear from the article by Professor Nouraei and others that there is a significant amount of overlap between specialisms when patients are first presenting with symptoms which ultimately result in being a pharyngolaryngeal or oesophagogastric cancer.

Clinicians and organisations need to be aware of this overlap, so that they can ensure they have the appropriate steps in place to ensure that these cancers are identified as early as possible to maximise the patient’s safety and survival chances. There needs to be an integrated approach between specialties and between primary and secondary care specialists to offer the quickest symptom-focused and patient-centred diagnostic evaluation.